Emotional Support Animal Evaluation Contract for Services
What is it?
An ESA evaluation is a request to be evaluated for an emotional support animal due to a disabling mental health condition.
What types can Spencer Psychology do?
We only evaluate for ESAs for housing. We do not do transportation evaluations (airplanes).
Do you certify the animal?
No. This is a common misperception of evaluations. To qualify for an emotional support animal, a provider is evaluating the person’s need, not the animal’s behavior or fitness.
Requirements
- You must have a current or recent therapist.
- Our evaluator must be able to staff with that therapist
To be evaluated at Spencer Psychology, you must already have a therapist (or recently have had a therapist). This can be someone local, or elsewhere. Our evaluator will contact your therapist to discuss your diagnosis, as our service does not include a full psychological evaluation but a mental health screening. If you have not been working with a therapist, we cannot do your ESA evaluation.
Disqualifying Circumstances
- An ESA evaluation is offered to candidates with a disabling mental health diagnosis, as determined by a current or recent therapist or other mental health practitioner.
- If you do not know your diagnosis, please ask your therapist prior to payment or registration with us.
- If you have a diagnosis of Adjustment Disorder, this is not considered disabling and you will not qualify for approval.
- Other mild diagnoses such as Z codes related to temporary phases of life also cannot qualify as disabling.
- Diagnoses that include animal abuse are disqualifying.
What does the evaluation include?
- Interview.
- Data collection (talking to your therapist).
- Filling out any required housing form or providing a letter of support for housing.
Refunds-Guarantees
- We cannot guarantee that the evaluator will find that you are qualified for an animal. Please be sure you do not have any of the disqualifying diagnoses before you begin.
- We will consult with your therapist first to learn your diagnosis and functioning. If your diagnosis does not meet criteria, we will stop the evaluation and refund the remaining portion of your fee (minus the time taken to speak to your therapist).
- If you discontinue the evaluation prior to your interview, any unused fee will be refunded (minus the portion used to speak to your therapist).
Fees
- The ESA Evaluation is not billable to insurance as it does not meet their requirement for “medical necessity”.
- Fees are self-pay for $375 .
- If you fail to show for your scheduled appointment or if you cancel less than 24 hours prior to your appointment, a late cancel fee/no show fee of $75 will be deducted from your overall payment, as your evaluator will have reserved this time for you on her schedule.
Client Name:
Enter client/child name
Electronic Signature of Client/Parent/Guardian:
Enter your full name
Date: